Levy: "There's a lot of interest in risk modeling, trying to figure out, for instance, when somebody presents to the hospital with atrial fibrillation, how do we know who is more or less likely to have adverse events? And I think applying those types of clinical decision rules can be helpful. There are abstracts looking at stroke care and syncope care, and expedited management of those patients, and, again, predicting who may or may not benefit.

"There's some interesting work, looking at tPA, thrombolytic administration in strokes, and, again, trying to predict who is more or less likely to have an adverse outcome using sort of cluster analysis of patients.

"There's a growing interest and growing use of observation units for care. Now we have these units that are really fully functional locations where patients for whom we're still figuring things out can go. And there are some nice abstracts showing that these clinical decision units -- one article refers to it as a multidiagnostic treatment unit -- that they beneficially affect length of stay and they can reduce hospital admissions, which is not entirely surprising.

"But it basically suggests that these are not harmful or they aren't practices just to avoid hospital admissions per se, but you can still get effective care delivered in an expedited manner and avoid an unnecessary or costly hospitalization with no detriment to the patient. So I think that's kind of cool stuff. It's stuff that we all sort of thought and knew, but it's nice to see it on paper, and it's nice to see it in diverse settings with some studies looking at this practice in the U.S. and this practice in Canada as well."

Sepsis

Levy: "In the area of infectious disease, there's a number of abstracts that are addressing sepsis, though not specifically ARISE or ProCESS. There are some nice abstracts looking at benefits of early antibiotic administration, absence of harm if you're wrong with your first initial antibiotic. So, we always worry about that. How do you know what the best antibiotic is for a given patient? We have protocols in place for healthcare-associated infections where you're supposed to go big guns in certain hospitals. Hospitals have different approaches, but you go with one set of antibiotics that really covers everything versus another set of antibiotics they would use for community-acquired infections.

"And knowing that, even when you get culture results back, that if you go with such empiric antibiotic choices, you don't cause undue harm. That's an important thing. There's a number of abstracts that look at early identification of sepsis patients using either electronic medical alerts or using what are called sepsis alerts, so getting triggered if you were sitting at the desktop looking at your patients and all of a sudden an elevated lactic acid pops up, that can then be engineered in the electronic medical record to trigger an alert to the physician that this patient may have sepsis.

"And, as it turns out, there's been a shift in emergency medicine towards less use of things like Bactrim or ciprofloxacin, which have been around forever and everybody's always used them for UTIs. And, as it turns out looking at these resistance patterns, resistance is anywhere around 25%, 30%, maybe even 40% to those antibiotics. The kind of older antibiotics like nitrofurantoin or Macrobid, which physicians moved away from about a decade ago, the resistant patterns are maybe 1%.

"So, understanding that can really help your practice and help guide your specific approach to therapy, recognizing again that these are single-center or maybe a couple of centers combined together and that the best approach is to really do a solution or to look to the information in your own facility in your own community because they do vary by region. And that's influenced by empiric antibiotic practices."

PCMH x ED

Levy: "There's an abstract that looks at how patients want to be cared for once they leave the emergency department. When patients leave the ER, oftentimes what we do is just hand them some paperwork and say, 'Here. Make a call and follow up with somebody.' But, really asking the patients what are their needs once they leave the emergency department? How we can facilitate ongoing management of their condition is a movement that is kind of taking over in medicine in general and that's talking to the patient, similar to what's going on in patient-centered medical home models.

"Surprising, right? But, asking the patients what they need and then trying to engineer the response to their needs rather than just anticipate or expect or tell them what we think they need. We're really hopeful that emergency medicine can be one of the leading organizations or leading specialties to help work with patients on that end.

"On both days, we are going to have representatives from different funding agencies such as the Patient-Centered Outcome Research Institute, the NIH, and different organizations available to talk with emergency medicine physicians, whether they're interested in research or not, to get a little insight into what is emergency care research and how are funding agencies perceiving the value of emergency medicine in the research continuum? And I think that's going to be really helpful, especially with this movement towards patient-centered outcomes."

Opiates

Levy: "Recently, Vicodin was changed in its scheduling to a Schedule II medication in an effort to really try to cut back on abuse of prescription drugs. And, so, a lot of states have been responding with legislation. And we have a number of abstracts, not just in the oral presentations, that are looking at statewide policies. And, so, I think those types of things are really important, from a health service perspective, to understand how we, as an emergency medicine community, are responding to both policy changes and the protection and safety of our patients."

Throughput

Levy: "We'll have presentations on ways to improve throughput or ways to improve delivery of healthcare from the emergency department setting. There's a growing popularity in emergency medicine to have a paraprofessional, somebody who is not necessarily trained in medicine, helping document. And that's a movement in medicine where documentation is really as important to some degree as the care you deliver. They always say, 'If you didn't document it, it didn't happen.'

"And that's fine and well, but I think a lot of it is also an interest to capture maximal billing because, if you don't document a certain number of systems reviewed and your review of systems, or you don't include a certain number of body systems on your physical examination, you can't bill at higher levels of care. And, so, whether that's really true value to healthcare or a way of maximal revenue capture, I think that remains to be seen. There are some abstracts that kind of suggest in both directions that having scribes does or does not have financial impact. One suggests that maybe it has a little bit of impact on relative value units for providers depending on who that provider is.

"How do you avoid the impact of high-frequency users of an emergency department on the rest of the emergency department patients? So, in certain settings, you'll have people who either have chronic substance abuse or chronic mental illness who come to the emergency department frequently. Or, you'll have patients with chronic pain issues, sickle cell patients who come to the emergency department frequently.

"And by putting in care plans and trying to identify which patients may or may not need certain things at the get-go or which patients are there for the tenth time in the past 2 months -- maybe they don't need to have that full evaluation or maybe we can put in a care path or a care plan just for them that really recognizes their own individual challenges and minimizes the potential impact that the care of this individual would have on somebody else, somebody who is there for chest pain. If I'm spending my time getting the extensive history from somebody who was just here 2 days ago for the same thing, that might have a negative or deleterious impact on another patient who is there for something that is relatively more acute."

ACA

Levy: "You'll also see some abstracts on how the Affordable Care Act impacts emergency departments and movement of patients through the emergency department. I think the jury's kind of still out depending on what state you're in, and if you're a red state or a blue state, and who expanded Medicaid and who didn't, and those types of things. But, all told, it does look like, with the initiation of new insurance for people, they recognize the emergency department as one of the immediate locations where they can go to get care. And, so, while ideally the Affordable Care Act is set to help establish medical homes and help transition people to stable locations for primary care, accessing those stable medical homes and primary care settings is challenging if you're somebody who hasn't engaged in the healthcare system."

Levy: "We're going to see a lot of information on not only personal protection, but community-level protection and responses to exposures like we had down in Texas where, clearly, there was some concern with the way the patient was approached, and understanding that in a situation like this it's okay to be wrong in saying someone does have the disease, but you really don't want to be wrong saying someone doesn't. It's an issue of [diagnostic] sensitivity and false negatives versus false positives.

"If somebody gets placed in isolation for a couple of days and they don't turn out to have Ebola, that's fine. It's an inconvenience for them and maybe for some of the caregivers. But, if it turns out that they do have Ebola, like this case in Texas, then that has dramatic implications at the community level and beyond. So, I think you'll see a lot of emphasis on that and maybe even some dissection and discussion about the CDC's initial approach and what their initial recommendations were, which have now been dramatically revised in the last few days for the more expensive level of personal protection that is needed.

"I think a lot of that reflects the American hubris, which is we have an entire section of the world that's been dealing with this for months and to not really learn from their experience, and to not really understand what they went through, and to speak to groups like Medecins Sans Frontieres and the people who are really on the front line. I think we, unfortunately, learned a lesson the hard way."

What else is exciting at this year's conference?

Levy: "Posters are going to be all electronic. There's going to be eight of them per presentation and another two of them throughout the conference at different locations in the conference menu where people can just walk up and click by topic, or click by investigator, or click by specific study on a screen, and if they want to look at abstracts, they'll be available for that. So, it's really on people's own time to look at abstracts if they're interested.

"Perhaps of biggest importance to conference attendees, Jeremy Brown, MD, who is the director of the Office for Emergency Care Research at the NIH, will be speaking on Monday afternoon. He'll spotlight why the office was created and what is the value to the emergency medicine community. That's going to run from 4:30 to 5:30 on Monday afternoon."

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